No Date Set for PECOS Requirement, Says CMS

Last year, the Centers for Medicare and Medicaid Services (CMS) delayed the implementation of a requirement that all physicians who ordered or referred services for Medicare beneficiaries to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS) because many physicians were unaware of the obligation. This requirement has been particularly problematic for physical therapists who furnish durable medical equipment in home health settings because claims for services ordered by a provider who is not enrolled in PECOS would be denied. Under this requirement, the ordering/referring providers will not see claims denials. Instead, the claims of providers who provide services under the order of a physician, including physical therapists, will be denied under this new requirement.

This week, CMS announced that there was an editorial oversight in a federal report that stated that the agency will implement the PECOS requirement July 5. This is incorrect. CMS has not yet determined when it will begin to apply the ordering/referring provider claim edit to ordering/referring providers who do not have a record in PECOS. CMS has stated that it will give providers ample notice before the ordering/referring provider claim edit is applied. Recent revisions to Change Requests #6417 and #6421 require Medicare Administrative Contractors to delay rejecting claims until they receive further direction from CMS.

Comments

I work in a state that requires physician referral in this situation the physician must be enrolled in PECOS and not the physical therapist, is that correct?
But if you are a PT working in a state with Direct Access then the PT is the referring provider and the PT must be enrolled in PECOS.
Is this correct?

Posted by kevin lacey
on 3/27/2011 11:10 AM

It is wise for all PTs to enroll in the PECOS system. Regardless of the state, direct access or not, the Medicare plan of care still has to be certified and re-certified by the physician. Also, for home health and durable medical equipment under Medicare, the physician order is needed regardless of whether the state has direct access to physical therapy services.